5. Non-specific infections of the kidney; Advanced prostate cancer

Question 1

List the non-specific infections of the kidney (7)

Answer 1

1. Acute uncomplicated pyelonephritis
2. Acute complicated pyelonephritis
3. Chronic pyelonephritis
4. Xanthogranulomatous pyelonephritis
5. Emphysematous pyelonephritis
6. Papillary necrosis
7. Pyonephrosis

Question 2

Acute uncomplicated pyelonephritis

Answer 2

Result of an ascending infection.

Symptoms:
o Shaking chills
o High fever for more than 2 days
o Flank pain
o Nausea and vomiting
o Frequent and painful urination
o Cloudy urine

Diagnosis:
- Urinalysis show WBC, RBC and bacteria (E.coli most common)
- Complete blood count: Increased CRP, ESR, procalcitonin and WBC. In
case of sepsis; low platelet count.
- Presence of antibody-coated bacteria is indicative of pyelonephritis,
and not cystitis
- Do US to rule out obstruction
- Contrast enhanced CT can confirm diagnosis, showing perfusion defects and parenchymal swelling.

Treatment: Ciprofloxacin or 3rd generation cephalosporins

Question 3

Acute complicated pyelonephritis

Answer 3

Result of an urological disease:
o Vesicoureteral reflux
o Ureteral stricture
o Stone
o DM
o Iatrogenic
o Pregnancy

Question 4

Chronic pyelonephritis

Answer 4

Incomplete treated and long-standing acute pyelonephritis. Will eventually cause atrophy and renal insufficiency. Many are
asymptomatic and condition is discovered incidentally.

May present with azotemia (HTN, visual disturbance, headache, polyuria)

Question 5

Xanthogranulomatous pyelonephritis

Answer 5

Rare disorder caused by an obstruction followed by infection, usually E. coli or proteus.
Progressive granulomatous inflammation with lipid-laden macrophages (xanthoma cells).

Causes progressive destruction of the parenchyma and can involve the perinephric fat and retroperitoneum as well.

Treatment is nephrectomy. Often cannot be distinguished from a tumor.

Question 6

Papillary necrosis

Answer 6

Coagulative necrosis caused by toxins that produce ischemia.

Passage of sloughed papillae can cause obstruction.

It can sometimes present as acute renal failure.

Causes:
Chronic analgesics, aspirin, phenactin
Sickle cell disease
DM
Sever acute pyelonephritis.

Question 7

Emphysematous pyelonephritis

Answer 7

A life-threatening, fulminant, necrotizing
pyelonephritis, associated with gas within the kidney and perinephric space

Acid fermentation of glucose by Enterobacteria produces gas.

A crepitant mass may be present.

X-ray shows air in the collecting system.

Question 8

Pyonephrosis

Answer 8

Infected, purulent urine in an obstructed collecting system.

Urinary obstruction in the presence of pyelonephritis may lead to collection of WBC, bacteria and debris in the collecting system, resulting in pyonephrosis.

Patients may deteriorate rapidly and become septic.

Ultrasound can demonstrate fluid-debris level or weak echoes in the dilated collecting system.

Drainage may be needed in addition to the antibiotics.

Uretheroscopy and lithotripsy is contraindicated in pyonephrosis,
- the infection should be treated with antibiotics and nephrostomy drainage.

If infection is severe, nephrectomy may be performed
or
percutaneous nephrostomy and anterograde treatment.

Question 9

Advanced prostate cancer types and incidence

Answer 9

Prostate cancer is the most frequent malignant disease in males, with 85.000 new cases each year in Europe. Most frequent between 65-75 years of age.

Acinar adenocarcinoma (95%)
Other types: 
Sarcoma of the mesenchymal cells. 
Transitional and squamous cell carcinoma
Mixed carcinosarcoma. - Poor prognosis. 

Classification:
• Manifest prostate cancer: Diagnosis by screening or symptoms
• Incidental prostate cancer:
- Discovered in a benign operative specimen
- Latent: Discovered on autopsy
- Rare form: Metastasis diagnosed with negative DRE.

Question 10

Where in the prostate does cancer usually occur

Answer 10

75% arise in the peripheral zone
20% arise in the transition zone
5% arise in the central zone

Question 11

Gleason score

Answer 11

A grading system that estimates the prognosis based on the differentiation of the cells under low-power magnification.
It grades the 2 most representative areas of the tumor (primary and secondary grade).

These 2 scores are added together giving a final Gleason score (smallest score is 2 an highest is 10)

• A single score of 4 or a final sum of 7 is predictive for a bad prognosis.

Question 12

Prostate TNM staging

Answer 12

• T1: Tumor not clinically apparent: Non-palpable
• T2: Palpable tumor confined within the prostate
• T3: Tumor extends throughout prostatic capsule
• T4: Tumor invades adjacent structures

Nodes:
• N1: Single regional node
• N2: Single or multiple regional nodes >2cm
• N3: Regional nodes >5cm

Metastases:
• M1a: Distant nodes involved
• M1b: Bone involvement
• M1c: Other sites involved

Question 13

Prostate cancer symptoms

Answer 13

Symptoms:
• Localized form shows no symptoms
• Involvement of the capsule: Obstruction of urinary flow can occur

• Advanced metastasis:
o Bone pain
o Weight loss
o Hematuria
o Hematospermia
o Impotence
o Anemia
o Urinary retention
o Fatigue
o Asymmetric swelling of legs
Serum PSA is the single most important test in the initial diagnosis of prostate cancer.
Normal concentration: 0 – 4ng/ml
PSA levels should be measured yearly after age 50.
To confirm the diagnosis we need to do a transrectal core needle biopsy.
Nuclear bone scan is the most sensitive test for bone metastasis.
Pelvic lymph node resection should also be done in suspicion for metastasis

Question 14

Treating prostate cancer

Answer 14

Hormonal therapy (palliative):
Most prostate cells are androgen dependent. 

Without androgens the prostate will atrophy.

However, the prostate tumor consists of androgen dependent AND independent cells.

Suppression of testosterone will only cause a 40% decrease in the volume of the prostate tumor.

Also, after 2 years hormoneresistance will develop and PSA levels will rise again.

Methods of androgen suppression; surgical or chemical castration.

Hormone resistant tumors are treated with chemotherapeutic drugs like mitoxantron
or taxanes, combined with steroids.

For bone metastasis we give bisphosphonates.

Urinary retention can be treated with TURP.